Value of advocacy

Sir: As the managers of the advocacy scheme in the area where Dr Gamble is based, we were dismayed, and not a little angry, to read his letter (Psychiatric Bulletin, September 1999, 23, 569-570). We have requested details of the evidence on which Dr Gamble has based his specific allegations, and we await his reply. In the meantime, we feel it is important to respond to his criticisms of independent advocacy, in the public setting in which he made them.

First, it should not come as a surprise if advocates and doctors sometimes give patients different information: survey after survey has shown that psychiatric patients frequently feel they have not been told enough about their medication, for example, and advocates have a legitimate role to play in enabling patients to make decisions about their options on the basis of information from a range of sources — not only clinical. If different pieces of information are at times ‘in conflict’, does that not merely reflect the often uncertain knowledge base of treatment in mental health? In our view, the only cause for alarm would be if anyone was giving patients information which was clearly false.

Second, the argument that because advocates see patients alone, it follows that they are “giving advice in private which others may not be aware of” (our emphasis) is logically flawed — and wrong. Mental health advocates adhere to a code of practice which states that they should not give advice to patients, nor offer their own opinion.

Third, Dr Gamble expresses concern about the “anti-medical establishment political agenda” and “destructive ideology-driven power” of “some advocacy movements” — including, apparently, our own service. Dr Gamble's use of terms such as political and ideology-driven we can forgive (and would be interested to debate further, in the context of mental health advocacy and the psychiatric system), but we take strong exception to the other labels he puts upon us. Our advocacy service operates in accordance with a policy drafted painstakingly over a period of some months, more than seven years ago, by a group which consisted of several representatives working in the local mental health service (including a consultant psychiatrist), as well as Mind staff and users. Underpinning the notion of independent advocacy described in this policy is a set of principles which affirm the legal and human rights of users of mental health services — principles which are to be found in many a patients' charter, in the Mental Health Act code of practice and even, increasingly, in the operational policies of NHS trust services. It is very worrying that such principles could be deemed anti-medical establishment and, worse, destructive.

Dr Gamble leaves his most outrageous accusation — of local advocates' “tacit encouragement of violence against staff” — till last. We are mystified as to why, if there have been genuine concerns of such a serious nature about employees in our service, no one has brought them directly to our attention.

We are very sorry that Dr Gamble's ‘exposure’ to advocacy during his training has made such a negative impact on him, but we also believe that the conclusions he draws from his limited experience are unwarranted. Of course there are sometimes problems in the practice of advocacy (just as there are sometimes problems in the practice of psychiatry), but we would expect any important concerns about our service to be discussed with us frankly and respectfully. We sincerely hope that other psychiatrists are more inclined to share the stand of Thomas & Bracken (Psychiatric Bulletin, June 1999, 23, 329) that psychiatry needs to move ‘away from a negative antipsychiatry view of advocacy to a more constructive engagement’.